Healthcare Provider Details

I. General information

NPI: 1548658552
Provider Name (Legal Business Name): CANDACE HOPE BURGESS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2014
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

232 QUEENS RD APT. 45
CHARLOTTE NC
28204-3247
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone: 910-269-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number224654
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: